Oscar LlorenteCity of Miami Beach
1700 Convention Center Drive
Miami Beach, Ftorida 33139
OFFICE OFTHE CITY CLERK
Email: B�cilmiamibeachfl.gov
Telephone: 305.673.7411
RECEIVED
DSC 15 2021
CITY OF MIAMI BEACH
OFFICE I F' "AP CITY CLERK
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as (check (J) all that apply):
❑ I am a resident of the City of Miami Beach for six months or longer.
Home Address:
❑ 1 have an ownership interest (for a minimum of six months) in a business established in the
City of Miami Beach (for a minimum of six months).
Name of Business:
Business Address:
te�K I am a full-time employee of a business (for a minimum of six months) and I am based in an
office or other location of the business that is physically located in Miami Beach (for a
minimum of six months).
Name of Business: <S Nl Ara K 057D1 c A a_ C t_=-r-kiN -1571(L
Business Address: 14 Ac o A L -M r4 'RD V✓! ► A pr t t __tc-gac- 7 F L
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"Ownership Interest" means the ownership of ten percent (10%) or more (including the
ownership of 10% or more of the outstanding capital stock) in a business.
"Business" means any sole proprietorship, sponsorship, corporation, limited liability company,
or other entity or business association.
\7
Under pena ies f�erjury, I declare that I have read the foregoing document and that the facts
stated in it re tr
e2.1 207-1
Signature Date
Printed Name